This story is from The Pulse, a weekly health and science podcast.
Dentists have been locked in a fierce battle with mail-order orthodontics company Smile Direct Club for years now. If that’s news to you, it may be because dentists, I learned, are mild-mannered, solitary creatures.
“They work in their own little, you know, people call it islands or one dentist that I’ve connected with calls it a cave,” said Paul Goodman, a dentist and consultant in Philadelphia. “They work in their own little cave because it’s just set up for dentists to work as solo practitioners.”
The private-practice model tends to silo dentists off from colleagues, he said. They typically only deal with their assistants and us, the patients who want to be anywhere but in a dentist’s chair.
So to get dentists to talk to one another, or really anyone outside their offices, Goodman started a Facebook group. There are about 18,000 members, and Smile Direct Club comes up a lot.
“I was sitting on a plane today next to a dude who worked for 9 hours on SDC [Smile Direct Club] stuff. Wanted to give him a piece of my mind. ”
Wrote one user.
“I would’ve given THE LOOK the entire time.”
At the top of the thread, a dentist had posted a close-up of some really messed-up teeth, apparently a patient of his, almost done with a Smile Direct treatment.
The anger extends offline, as well.
“Do not put our patients to the risk. Do not take them for granted. And don’t put plastic aligners on every person who walks through your door,” said Chad Gehani, head of the American Dental Association.
The group was an early and vocal critic of Smile Direct. Gehani said he first heard about it after his patients came in with complications.
“There was one particular patient who came to me for a root canal. But besides the root canal, there was the loose tooth, the tooth [was] just hanging in the air,” said Gehani.
Orthodontics is more complicated than most realize, he said, and some people just aren’t good candidates for aligners in the first place. He doesn’t think Smile Direct cares.
“They just feel that they can just put [in] a plastic appliance, as if those are nails in the wall and they just want to align those nails in one condition,” Gehani said. “The teeth are not like nails in the wall. The teeth are teeth, and the teeth are attached to the jaw bone and to the gum and to the head.”
Before getting aligners, he said, you need a real, clinical evaluation in a dentist’s office, and Smile Direct won’t give you that.
“They are not looking at the soft tissue. They are not looking at the bone condition. They are not looking at the pockets, like how their gum condition is and how all the gums are receding,” said Gehani. “They are not looking at all of those things.”
All orthodontic treatments come with risks. If your gums or jaw have underlying disease, teeth can get moved right out of your mouth. Hidden impacted teeth and cavities can blow up under aligners — and if teeth don’t move in just the right way, your bite goes way off.
Smile Direct, though, says the concern voiced by Gehani and others is overblown, malicious even. When the company’s top dentist talks about its detractors, he sounds a bit like he’s talking about some kind of mafia.
“We don’t cater to the organized dentists and organized dentistry. We don’t pay to them. They’re not our customers,” said Jeffrey Sulitzer, Smile Direct’s chief dental officer. “We give [customers] what they want, not what organized dentistry wants.”
If you’ve gotten an email from Smile Direct with the greeting, “Hello Future Grinner,” it was probably signed by Sulitzer. He owned a few dental practices, and worked in insurance before Smile Direct. To him, the company is all about increasing access to affordable care.
“They liked the market the way it is. You have to go to them. They’re the ones earning the big dollars,” he said of traditional practices. “They don’t want nobody messing with lower fees.”
He tells me Smile Direct is simply meeting a consumer need, and leveraging new technology to do it in a smarter way. Disruption can ruffle some feathers.
Visiting the ‘SmileShop’
So I headed to a Smile Shop, one of Smile Direct’s storefront locations, to see what he’s talking about. It looks a bit like an Apple Store from the outside, it’s in a busy section of downtown. They wouldn’t me let record audio inside, so I just took notes.
I walked into a room with a lot of purple and white and signed in on a tablet. They asked me what kind of smile I was after. And then they pulled out this big wand attached to a monitor.
It was long and white, looked like those small vacuums you might use on a couch. It’s called an iTero. A dental assistant put one end in my mouth and all around my teeth, flashing a white light and taking, I’m told, thousands of images per second.
As the wand moved, a 3D rendering of my teeth — plaque, fillings and all — filled a screen with uncomfortably high resolution.
A supervisor came up and double-checked my scan. I wondered: Is she a dentist?
No, before working here, she told me, she managed a North Face. But after a few clicks around my 3D teeth, she decided everything checked out. I was shown the price list — did I want to pay an $1,800 lump sum or do a payment plan? A dentist will review the scans remotely, I’m told, and give the final OK before my aligners start showing up in the mail.
The whole thing took 20 minutes, the staff was dressed in street clothes instead of scrubs, and there wasn’t a single actual dentist in the building. No one told me to see a dentist before my visit, or asked if I had one. But when I looked at the paperwork I signed, apparently my dentist was supposed to have played a major role in all this:
“My dentist took X-rays of my teeth.
My dentist checked for and repaired cavities, loose or defective fillings, crowns or bridges.
My dentist checked my X-rays and I have no shortened or resorbed roots.
My dentist checked my X-rays I have no impacted teeth.
My dentist has probed or measured my gum pockets and says I do not have periodontal or gum disease…”
Just by signing, I had checked yes to all these questions.
“We do not ask them to prove they’ve been to a dentist, but they attest that they have been,” Sulitzer said of Smile Direct’s patients. “In essence, they say, ‘Yes, I’ve been to the dentist within six months, and they check the box and say ‘Yes.’”
I didn’t get aligners, but weeks later I was still getting robocalls saying my new smile is waiting. So I asked Sultzer: How do you know for sure I’m a good candidate? Why not get my dentist, any dentist, to sign something saying I am? I told him that would probably silence some critics.
“They want to make it like the old model, ‘Yeah, get a signature, go to a dental office,” he said. “Does that make any sense? What you’re trying to do is you’re responding to naysayers that are dentists in the communities that are trying to come up with reasons of why we should fail.”
Smile Direct isn’t doctor-focused, he said, it’s concerned with the patient. Or, the customer. Sulitzer used the terms interchangeably as we talked. And, he said, anyway the company intentionally only takes on easy cases, just moving the front smile teeth. Dentists and organized dentistry just can’t stand all the winning.
“They’re so frustrated because it’s not failing. It’s not creating problems. It’s been so successful and efficacious,” he said. “They’re trying to figure out how they can slow this thing down. So that’s really what you’re faced with. And we’re not gonna put up barriers just because they’re not happy with our success. It’s not going to happen.”
Smile Direct is big on social media, and smiling customers speak for themselves, he said. Reputation is everything.
“In our world, we don’t see bad outcomes,” Sulitzer said. “We have over 750,000 cases treated. When you look at the social media, the results are amazing.”
What the patients say
It’s pretty easy to find loads of real people posting online about their beautiful Smile Direct smiles. There’s a lot on Instagram, a bunch of unofficial Smile Direct Facebook groups. The majority of the posts are toothy selfies, grateful for Smile Direct’s transformation.
Orthodontics often isn’t covered by insurance. It’s clear Smile Direct makes the lifelong dream of straight teeth more affordable for more people.
But not everyone gets a happy ending. There are posts like this one from a young woman:
“Totally regret doing this, my bite has changed DRASTICALLY! Now I bite in the front middle of my mouth, my back teeth are tilting in and my bottom front are rubbing my top front.”
“My tongue and lips have been torn to shreds and now I feel like my two front teeth are caving in.”
“My top gums are inflamed and I was bleeding a lot. I’m scared to put them back in.”
People share symptoms and ask medical questions — things more suited to a dentist’s office than a Facebook group.
“Please reassure me this is normal!”
A bunch of people do, but none of them are dentists.
In theory, you can call your Smile Direct dentist to ask such things, but you have to get through customer service first.
The worst cases sometimes end up walking into a brick-and-mortar orthodontist’s office.
‘They must be desperate’
I visit Joshua Davis’ orthodontics practice in Philadelphia, and ask how many such patients he sees each year.
“I mean, I’ve had two in the past week and a half,” he said.
Smile Direct customers will show up with misaligned bites, painful jaws, Davis said.
“I suspect it should pick up even more over time,” he said. “I think they do great at marketing. And I don’t think the patients are fully aware that it’s different than going to an orthodontist’s office.”
At his practice, Davis has a room with the same iTero machine Smile Direct has, but it’s not all he has.
“We take a panoramic X-ray, we take a cephalometric X-ray — can measure the bones,” he said. “Then we also have a cone beam CT scanner, where I can get a 3D image of the bones of the head and the teeth.”
None of this is cheap, and almost every orthodontist is also a small-business owner. They have to keep their practices afloat. So I had to ask: Is Smile Direct just winning too much? Cutting into profits, stealing patients. Davis said he has 80 more patients to see in the afternoon after we finish speaking.
So he, at least, isn’t feeling the squeeze. He said guys like him and Smile Direct can actually coexist, to a degree.
“I do think Smile Direct Club could offer a low-cost, retreatment option for that really slim segment of the population,” he said.
What’s retreatment? It’s what happens when your parents got you braces, but you couldn’t be bothered to wear a retainer, and now you need to tighten up.
“But they’ve taken it and tried to deliver that treatment to the masses,” Davis said. “And I think that that’s inappropriate and unethical.”
He said Smile Direct sacrifices safety to get the most paying patients/customers possible. But a dentist or orthodontist somewhere has to sign off, remotely, on every aligner.
“They must be desperate,” Davis said about those tele-dentists. “The business environment for them might be that they’re struggling. People do desperate things in desperate times.”
Many dental and orthodontics practices are independent businesses. Davis said that can be costly on its own before factoring in the enormous debt dentists take on in school.
He told me about a former patient who decided to follow in his orthodontist’s footsteps. First, he had to get his bachelor’s degree.
“Which is like $90,000 a year or something like that,” said Davis.
Then, finally, another three years of orthodontics school, which can be even more expensive.
“I don’t know the exact numbers, but he’s going to leave school with $1 million worth of debt, $1 million,” he said.
Paying that loan will cost $6,000 a month, for 25 years. Can you really blame some dentists for essentially driving a Smile Direct Uber for an hour here and there?
I asked Sulitzer for Smile Direct’s numbers on how many of its patients end up with complications or failed treatments, and have to see orthodontists like Davis.
“Well, so let me ask you this: Where are those numbers in traditional practice? Do you have anything to compare them to?” Sulitzer said. “And that’s the answer. There aren’t any.”
He’s right, comparable numbers are hard to find. This is all pretty new.
But a couple of days after we spoke, Hindenberg Research, a market research firm, came out with a scathing report on Smile Direct Club called, “Moving Fast and Breaking Things in People’s Mouths.” It pointed to review-site horror stories, and warned that crippling state regulations are right around the corner. Far from the future of orthodontics, it warned Smile Direct was about to fizzle out.
Smile Direct’s stock did take a hit, at first, but things stabilized and recovered pretty quickly in the end. There are even real competitors on the horizon.
Braces are still crazy expensive. People still want perfect smiles.